Today, you’re going to learn how to heal body dysmorphic disorder using cognitive behavioral therapy CBT – how to become less preoccupied with your appearance, overcome body image problems, and get on with what is important in life.
Does Appearance Matter?
First impressions don’t just depend on what we look like, but also on how we behave.
Faces have many functions. Facial expressions allow you to express yourself and communicate emotions, such as happiness, sadness, disgust, and anger.
Communicating with other people involves more than body image. It also involves words, tone of voice, facial expressions, and body language.
The combination indicates whether the other person is interested in what we’re saying, or not.
But faces also indicate attractiveness, age, ethnicity, racial characteristics, etc. This is why faces and body image in general can cause distress when something about our body image worries or disturbs us.
Although paying attention to your appearance is normal and healthy, becoming excessively concerned or anxious about your body image can become problematic and negatively impact your well being, causing issues like Body Dysmorphic Disorder.
What Is Body Image?
“Body image” refers to our internalized sense of what we look like, based on which we judge our external appearance. This makes body image very subjective.
For instance, people with eating disorders have a perception of their body size that differs greatly from their actual size. People with anorexia might feel normal or even fat, when in reality they are very thin.
But for most of us, what we think we look like (subjective appearance) and how we appear to people (objective appearance) isn’t so different.
Have You Got A Body Image Problem?
What distinguishes someone with a normal body image from someone who has a body image problem is the way they think and act.
In fact, research shows that the way someone feels about their appearance has far more influence on their life quality than how physically attractive they are to others.
Not being completely satisfied about certain body parts or thinking that you should lose a few pounds, or having an unusual appearance or a significant disfigurement, doesn’t mean that you have a body image problem.
But if thinking about your appearances is preventing you from participating in certain social activities or getting in a relationship, then you might have a body image problem.
1. Body Dysmorphic Disorder (BDD)
Body dysmorphic disorder (BDD) is characterized by an extreme preoccupation with one or more features that others don’t usually notice or find abnormal.
People with BDD usually feel they are ‘not right’ or even ugly and they are very self-conscious. They often compulsively check their mirrors and might resort to needless cosmetic procedures, which have little effect on reducing their preoccupation and distress.
Do I Have Body Dysmorphic Disorder Test
The following are some BDD symptoms:
1. You feel that you have one or more features that are very noticeable, abnormal, ugly or ‘not right’.
2. Others close to you would tell you that these feature(s) are not really noticeable, abnormal or ugly.
3. If you add up all the time you worry or brood about your features, it exceeds an hour every day.
If these symptoms don’t apply to you then you don’t have BDD. If they do, then you may have BDD.
However, only a health professional can give you a firm diagnosis, as there could be other problems, such as an eating disorder that may account for your body image concerns.
Other issues that might be associated with BDD:
Your worry about your feature(s):
- cause you marked distress
- significantly interfere with your social and work life
- has a significant effect on dating or interferes with your ability to form an intimate relationship
2. Psychogenic Excoriation
Also known as ‘compulsive skin-picking’, psychogenic excoriation is characterized by a broader range of behaviors such as excessive scratching, picking, gouging, cutting, digging, rubbing or squeezing of the skin.
Compulsive skin-picking (CSP) may be a symptom of BDD as a way of coping with minor irregularities in the skin that are hardly noticeable to others.
CSP can also develop into an impulsive behavior and the original reason for picking may be forgotten.
CSP can also be a symptom of other mental health issues such as obsessive compulsive disorder (OCD) or borderline personality disorder (BPD).
One of the best psychological therapy recommended for overcoming CSP is a method called ‘habit reversal’.
The following are some CSP symptoms:
You repeatedly scratch, pick, gouge, dig, rub or squeeze your skin to the point where you end up with a noticeable skin damage.
1. You repeatedly scratch, pick, gouge, dig, rub or squeeze your skin to he point where you end up with a noticeable skin damage.
2. The urges to scratch, pick, gouge, dig, rub or squeeze your skin are intrusive or irresistible.
Other issues that might be associated with CSP:
The behaviors associated with skin-picking are
- causing you marked distress
- time consuming or interfere with your social and work life
- resulting in medical problems, such as infections or significant scarring.
3. Skin Disorders And Disfigurement
Individuals with skin disorders or disfigurement can have body image problems related to preoccupation, shame and worry about appearance.
They may also have to cope with social problems such as others’ curiosity, staring, comments and questions, and teasing and bullying.
These responses from other people are a natural human reaction, but can make the ones with body image problem slip into a pattern of avoiding social situations.
Medical and surgical solutions are not always possible. This is why individuals with skin disorders or disfigurement have to work on understanding others’ responses and learning to anticipate problems by taking initiative in social situations.
Trichotillomania is characterized by repeated hair-pulling, whether it was the hair on the scalp, eyebrows, or even one’s armpit and pubic area hair.
Pulling their hair, might make these people feel less tense and even give them a sense of gratification.
However, the consequences might leave them with feelings of shame and they will try to cover any resulting baldness or patches.
Like compulsive skin-picking, hair-pulling can sometimes be a symptoms of BDD when the individual pulls their hair as a way of coping with a ‘defect’ in their appearance.
5. Anorexia nervosa
Anorexia nervosa is an eating disorder in which the individual keeps their body weight low by restricting what they eat.
A BMI below 17.5 in adults is one of the common physical characteristics used to diagnose anorexia.
To calculate you BMI you need to divide your weight (in kg) by your height (in metres) squared, or use the automatic calculator.
Individuals suffering from anorexia nervosa are preoccupied with their shape and weight. They might know that they are underweight and that others do not view them as ‘fat’, but their might fear losing control and becoming overweight.
Being preoccupied with being overweight isn’t a symptom of BDD.
However, some individuals with anorexia nervosa suffer from BDD when they’re not only preoccupied by their weight and shape but also feel ugly or scarred on their face.
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How to Heal Body Dysmorphic Disorder Using Cognitive Behavioral Therapy?
Why A Cognitive Behavioral Approach?
One of the best approaches to overcome body image problems is Cognitive Behavioral Therapy (CBT).
CBT aims to deal with symptoms of body image problems rather than analyzing their deep-seated underlying historical causes (traditionally the focus of psychoanalysis)
The starting-point for CBT is the idea that the way we think, feel and behave are all intimately intertwined, and that by changing the way we think about ourselves or our experiences, the way we feel and what we are able to do, changes as well.
For instance, by identifying and challenging your automatic depressive thoughts, you can change them into more realistic ones and change the way you feel.
Effective cognitive behavioral treatments have been developed for different types of anxiety disorder, such as panic disorder, generalized anxiety disorder, specific phobias, social anxiety, and Obsessive Compulsive Disorders (OCD), as well as for other conditions such as eating disorders like bulimia nervosa and body image problems such as Body Dysmorphic Disorder (BDD).
#1. Become Aware Of Your Body Image Problem
1. Identify The Problem Feature
Identify the feature(s) of your body that you dislike or would like to improve and precise for each feature whether you are seeking a cosmetic or dermatological procedure for the feature either now or in the future.
Estimate the percentage of concern allocated to each feature.
2. Identify The Noticeability Of Your Problem Feature
You may find it helpful to discuss with a trusted friend or therapist how noticeable your feature is to other people (if you do not camouflage yourself, e.g. with clothes, padding, makeup, and the feature has not been pointed out to them)
You could ask this person to rate the features using a scale from 0 to 10 without him or her knowing how you rated yourself.
3. Identify The Severity Of Your Body Image Symptoms
Rating the following elements will help you identify the severity of your body image problem, but also monitor your progress in overcoming it:
Frequency – How much time on an average day you are occupied by worries about your appearance and related behaviors (e.g. checking, comparing) over the past week?
Distress – How much distress these worries have caused you? Or how much distress do you experience when confronted with a situation you wanted to avoid?
Handicap – How much have your worries about your appearance and related behaviors (e.g. checking, avoiding) interfered with your professional life and personal life?
Avoidance – How much have you avoided situations or activities because of your feature(s)?
Situations and activities avoided might include:
- A party or social gathering
- A medical examination
- Exercising in a gym
- Wearing a swimming costume on a beach
- Being physically close to someone
- Certain types of clothes
- Certain types of lighting looking at picture in magazines or on TV
- All or certain mirrors that are unsafe
- Having a photo or video taken by someone else
- Looking at old photographs
4. Identify Your Rituals And Safety Behaviors
Your safety behaviors are the things you may be doing excessively or more precisely because of your preoccupation with your problem feature(s).
The goal here is to identify these safety behaviors and work on changing them.
These rituals and safety behaviors might include:
- Checking your feature(s) in mirrors and other reflective surfaces (e.g. cutlery, windows, CDs, etc)
- Using a particular light to check your feature(s) in a mirror
- Checking your feature(s) by taking photographs of yourself
- Checking your feature(s) by feeling it/them with your finger
- Comparing your feature(s) with others in magazines or on TV
- Comparing your feature(s) with those of other people you meet
- Comparing your feature(s) with old pictures of you
- Wearing something (e.g. jewellery a baseball cap, hat, scarf, baggy clothing) to divert attention from your problem features
- Asking others to confirm the existence of a defect in your problem feature(s)
- Seeking reassurance about whether your problem feature(s) has/have gotten worse
5. Identify The Impact Of Your Symptoms On Your Life
The next step is to rate the impact of your problem feature(s) on your everyday life.
To do that, consider the following question and rate on a scale from 0 to 10 the impact of your problem feature(s) on each area of your life:
* If you are in a long-term relationship, to what extent does your preoccupation with your feature(s) affect your relationship (e.g. number of arguments, enjoying activities together)?
* If you are not in a long-term relationship, to what extent does your preoccupation with your feature(s) currently affect you and your dating or developing a relationship?
* Regarding your work or studies, to what extent does your preoccupation with your feature(s) currently interfere with this area?
* Regarding your social life (e.g. parties, outings, visits, home entertainment), to what extent does your preoccupation with feature(s) currently interfere with this area?
* Regarding your private leisure activities (e.g. reading; gardening; collecting; walking alone, etc.), to what extent does your preoccupation with your feature(s) currently interfere with this area?
* Regarding your mental health (e.g. depression, anxiety, feelings of shame, etc.), to what extent does your preoccupation with your feature(s) currently interfere with this area?
#2. Focus More On What’s Important To You
Body image problems are mainly the result of being overly focused on your own appearance, including comparing it with other people’s appearance and appearance in the media.
The goal now is to understand your values or what you want your life to stand for.
By identifying your values and acting towards them, you can bring balance into your life and make it less dominated by appearance.
It’s important to keep in mind that values are not goals.
Values are like compass points while goals are part of this process.
With values, there is no destination because there is always something more you can do to work towards them.
For example, if your value is to be a good partner, there will always be things you can do to be a better partner. These things are goals you work on achieving like spending more time with your partner.
Practical Exercise – Identify Your Values
To identify your values consider the following:
* Imagine what aspects of life you would be engaging in if you were not preoccupied with your appearance.
* Brainstorm activities and interests you can think of, and consider which might be in line with your values.
* Remind yourself of what you used to value or aspire to before the body image problem.
* Consider what you would do if you weren’t afraid of what other people will think, or afraid of failing.
Identify your values for each area of your life (intimacy, family relationships, social relationships, work, education, recreation, spirituality, physical health, mental health, etc)
#3. Describe Your Goals
After identifying the problem feature(s), its impact, and the safety behaviors you’re using, write down a description of your goals relating to the problem feature(s).
Start with short-term goals that are easier to tackle, and set yourself a realistic timeline by which you intend to move onto the next set of goals.
Practical Exercise – Setting Goals
For example, someone might feel very preoccupied and ashamed about their skin, they might waste so much time applying make-up each time they have to leave the house.
Some of the goals to tackle this problem might involve the following:
- Cutting down the number of foundations they use
- Stop comparing their skin with others
- Stop picking their skin and let it heal by itself
- Inviting a friend for a coffee
- Meeting up with friends
- Going swimming again
- Go out to shopping centers
- Dating and developing a long term relationship
Make your own goals as specific and realistic as possible.
If you can’t imagine what a healthier alternative could be, consider the following:
* What did you do before you had a body image problem?
* If you had a friend, who was the same as you but without a body image problem, what would they do?
* What would a healthy role model of yours do?
Your goals should relate to your values in life and tackle what you have been avoiding.
Regularly review your progress and rate it on a scale from 0 to 10.
#4. Change Your Thoughts
Body image problems often occur when your thoughts become fused with facts. This makes your reality very unpleasant, but also distorted.
For instance, if you feel ugly, your ugliness is taken as a given fact and you assume that others will view you the same way.
Most people respond by trying either to escape from the thoughts and images or to control them, but that seems to only intensify their impact on your body image problem.
This is why you need to change relationship with your thoughts and images and treat them as ‘just thoughts’ or ‘just a picture in my mind’.
1. Step Back From Your Thoughts
The first step is to distance yourself from your unhelpful thoughts and notice them with curiosity without believing them to be true.
Then identify the ways in which your thinking might be affected by your body image problem, and take these negative thoughts with a huge pinch of salt.
Think of these intrusive thoughts as body shame propaganda, trying to lower your morale and keep you preoccupied and distressed.
Practical Exercise – Labeling Your Thoughts
Write your intrusive thoughts down.
‘I am having a thought that I am fat.’
‘I am having a memory of being bullied as a child.’
Challenge your distorted thoughts by asking yourself the following questions:
1. What evidence do I have that what I believe is actually true?
2. Am I confusing a thought with a fact?
3. Am I falling into a thinking trap (e.g., catastrophizing or all-or-nothing treatment)?
4. What would I tell a friend if he/she had the same thought?
5. Am I blaming myself for something which is not really my fault?
6. Am I taking something personally which has little or nothing to do with me?
2. Watch Your Thoughts Pass By
The goal here is to distance yourself from your thoughts by noticing your intrusive thoughts without engaging with them, rather watch them pass by like being on the pavement, watching cars pass on a road.
Practical Exercise – Distancing Yourself From Your Thoughts
* Get into a relaxed position and just observe the flow of your thoughts without engaging with them.
* Imagine sitting next to a stream with a number of leaves on the surface of the water, drifting slowly downstream.
* When thoughts come, put each thought on a leaf, and watch the leaf slowly moving away from you, drifting out of sight. Repeat the same with every thought that comes to your mind.
* When you are ready, bring your attention back to present and notice your body sensation and sounds around you, then slowly open your eyes and get back to life.
3. Broaden Your Attention
Our attention seeks out the subjects that interest us, which makes it more aware of them.
This is why one of the main reasons you’re struggling with body image problems, is the fact that a huge portion of your attention is on how you look, constantly monitoring your felt impression or picture in your mind.
When you re-focus your attention away from your inner world and onto the outside world, you give your mind a rest and allow yourself to take in what the world has to offer.
Practical Exercise – Adjust Your Attention
* Every time you notice that your mind is self-focused, immediately and deliberately refocus your attention on to the task (e.g. having a conversation, studying, working, etc.) or the environment around you.
* If you have no specific task to do, refocus on your environment by becoming more aware of:
- the various objects, colors, patterns and shapes around you (e.g. decor, cars on the street, trees)
- the sounds you hear (e.g. the sound off traffic, a clock ticking)
- what you can smell (e.g. scent of flowers, traffic fumes, fresh air)
- what you can taste (in the case of food or drink)
- the physical sensations you feel (e.g. whether it is hot or cold, the ground beneath your feet)
As you become more aware of your body image problems and how you can control it, the next is exposure – facing situations that you have been avoiding because of your anxiety that something bad might happen.
Doing this, will help reduce your fears and anxiety and change your beliefs about your body-image.
1. Gradual Exposure
Exposure needs to be done in a gradual manner and without using any safety seeking behaviors (e.g. keeping your head down, using excessive make-up, wearing bulky clothes, keeping your hand up to your face).
Remind yourself that anxiety, though uncomfortable, will not damage you. And that avoidance though relieving, will reinforce and intensify your body image problem.
Practical Exercise – Exposure Experiments
Step 1. Write down a hierarchy of fears
Write down a list of the things you tend to fear or avoid because they activate your worries, such as activities, situations, people, words or ideas.
Order the items based on the amount of distress they cause.
Step 2. Face your fear – ‘just do it’
Start with the least item you fear and make a plan to deliberately face it.
Make exposure long enough and keep facing the same item until you feel comfortable enough to move on to the next item on your list of fears.
Step 3. Do not use anxiety-reducing strategies
Exposure should be done without anxiety-reducing strategies such as alcohol, drugs and other safety-seeking behaviors (e.g. obtaining reassurance).
‘Fully engage’ with the situation and face any intrusive thoughts or uncomfortable sensations.
If you use a safety-seeking behavior, you need to redo the exposure, or expose yourself again to the previous item, until you become comfortable enough.
Paying attention to your appearance is normal and healthy, but when you become excessively concerned or anxious about your body image, it becomes problematic.
Body image problems such as Body Dysmorphic Disorder can hinder your well-being and restrict your possibilities in different areas of your life.
1. What Additional Problems May Coexist With Body Image Problems?
People suffering from body image problems might also have other issues that make their body image issue harder to treat.
Feelings of depression come on as a result of the frustration experienced because of the body image problem.
This kind of depression, often, isn’t a full-blown clinical depression, but rather experience of mood swings, irritability and a sense of frustration, poor concentration, disturbed sleep or appetite, being socially withdrawn or inactive, and being very negative in your thinking and brooding a lot on the past.
2. Social Anxiety
Most people with body image problems suffer from varying degrees of social anxiety and worry what other people think about them.
Individuals with social anxiety might fear doing or saying something that will embarrass or humiliate them. They might also fear that other people will see them blush, tremble or look anxious.
As a result, they try to avoid talking to strangers, eating or drinking in public, participating in meetings, and drawing attention in general.
When it is persistent and chronic, social anxiety, is often linked to low self-esteem and might be diagnosed in addition to BDD when the individual is overly preoccupied with their appearance.
3. Obsessive compulsive disorder (OCD)
OCD is characterized by recurrent intrusive thoughts or urges that the person finds distressing or disabling, such as thoughts about contamination, harm, aggression or sexual thoughts, an excessive need for order.
How Is Body Dysmorphic Disorder Similar To OCD?
Symptoms of OCD and BDD might overlap – for instance, a person may believe that their skin is contaminated resulting in compulsive washing or compulsive skin-picking.
4. Generalized anxiety disorder (GAD)
Generalized anxiety disorder (GAD) is a condition that involves persistent worry that is difficult to control.
For a diagnosis of GAD to be made, the anxiety should occur most of the time about issues such as relationships, health, money, etc. and not be focused only on body image.
Symptoms of GAD might include:
- being easily fatigued
- difficulty concentrating
- muscle tension and headaches
- sleep disturbance
5. Alcohol and substance misuse
Some people cope with body image problems by excessive use of alcohol or illegal drugs.
However, alcohol and substance misuse become then a problem.
2. How Does Body Dysmorphic Disorder Start?
Understanding how you have come to develop a problem can be useful and essential in overcoming it.
Possible causes for body image problems are divided into three groups of factors:
1. Factors that have made you vulnerable to developing symptoms (such as childhood abuse, trauma, genetic inheritance, etc.)
2. Factors that have triggered your symptoms (for example, experiencing acne or disfigurement, living or working in an environment that places exceptional pressure to ‘look’ a certain way)
3. Factors that have helped maintain your symptoms (such as particular patterns of thinking and acting).
1. Genetic factors
The fact that a mental health problem, such as BDD or eating disorder, runs in the family might increase your risk of experiencing a body image problem.
But it is also possible to develop a body image problem without any genetic risk.
2. Psychological factors
Certain aspects of your personality, such as being a perfectionist or excessively shy and reserved, can make you more vulnerable to developing a body image problem, especially when combined with one or more triggers.
Bullying is not uncommon during adolescence. Many people who suffer from body image problems can recall being picked on for their appearance.
Bullying can also occur in relationships. The partner who knows you well can pick on your insecurities, such as being called fat or ugly, which can be taken as confirming evidence.
4. Social factors
Some cultures put a great emphasis on looking attractive. For instance, plastic surgeries in Brazil are very common with 1.2 million surgeries carried out every year.
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- Portions of this article were adapted from the book Overcoming body image problems including body dysmorphic disorder, © 2009 by Alex Clarke, David Veal, and Rob Willson. All rights reserved.